Chapter 2: Health History and Interview

One technique of therapeutic communication is silence. What does silence allow the patient to do?

Decide how much information to disclose

A group of students is reviewing for a quiz on verbal and nonverbal communication. The students demonstrate a need for additional studying when they identify which of the following as an example of nonverbal communication?

Laundry list

The nurse is conducting a patient interview and responds to the patient in a way that encourages the patient to more completely describe his or her problems. What is this called?

Promoting elaboration

During the review of systems, a client reports having difficulty with urination and with establishing an erection. Which additional information should the nurse recognize as the highest priority to assess at this time?

Sexual history

What information aids the nurse in assessing possible biases in the data collected in the health history?

Source of information Designating the source helps the nurse and reader assess the type of information provided and possible biases.

An older client arrives for an appointment in the community clinic. Which approach should the nurse use when communicating with this client? Select all that apply.

Speak clearly Avoid jargon Show respect Use simple terms

When assessing the gastrointestinal system, the nurse correctly asks, "Do you have any trouble swallowing?"

True

During an assessment the client says "I've been having bad pain in my left leg for a week." In which section should the nurse document this information?

chief complaint

A middle-aged client has an appointment for a routine physical. Which type of assessment is the most appropriate for the nurse to complete?

comprehensive

A client is being admitted to a medical unit with an acute illness. The nurse would plan to gather information using which tool?

comprehensive health history

The nurse is reviewing the medical record before meeting a new client. In which phase of the interview process is the nurse working?

pre-interview

The nurse is completing a comprehensive assessment with a client experiencing a lung infection. Which information is essential to document within risk factors?

tobacco use

A client reports difficulty sleeping. Which question would be the most effective way for the nurse to open the interview?

"Can you tell me about your sleep problem from when it started until now?"

The nurse recognizes that an example of subjective data would include:

A pain rating of 7

A client recovering from surgery develops acute chest pain. Which type of assessment should the nurse complete with this client?

Emergent An emergent or emergency assessment focuses on a specific problem that may be life-threatening. This type of assessment focuses on circulation, airway, and breathing (CAB) when cardiac arrest is suspected. A focused assessment focuses on the client's current problem. The client's symptoms, age, and this history will determine the extent of the physical examination to perform. A follow-up history is a form of a focused assessment. The client is returning to have a problem evaluated after treatment. Data is gathered to evaluate if the treatment plan was successful. A comprehensive assessment is completed when admitting a client to a facility.

The nurse is interviewing a client in the clinic for the first time. The client appears to have a very limited vocabulary. The nurse should plan to

use very basic lay terminology.

The nurse is preparing to assess a female client's activities related to health promotion and maintenance. Which question would provide the most objective and thorough data?

"Could you describe how you perform self-breast exams?"

When using the CAGE questionnaire, the nurse elicits three affirmative responses when asking the client about alcohol use. The question most appropriate to ask next would be

"Do you ever drink then drive?"

A client states, "My wife died two months ago today." Which of the following responses would be most appropriate?

"How does that make you feel?"

The nurse suspects that a client is experiencing alcohol abuse. When completing the CAGE questionnaire, the nurse can confirm the client is having guilty feelings when she makes which statement?

"My family doesn't deserve my bad behavior."

Which observation would cause the nurse to suspect an abusive situation? Select all that apply.

-A caregiver of a cognitively intact older adult dominates the interview. -A pre-schooler rubs her perineum and complains of it hurting.

A client reports pain as being 7 on a scale from 1 to 10. In which area of the symptom should the nurse document this information?

Characteristic

A client states that the reason he has come into the clinic is for a routine annual physical. In what section of the health history would you document this information?

Chief complaint Chief Complaint(s)-Sometimes clients have no specific complaints. Report their goals instead. For example, "I have come for my regular check-up" or "I've been admitted for a thorough evaluation of my heart."

A nurse is creating a genogram of a client's family health history. The nurse should use which of the following symbols to denote the client's female relatives?

Circle

The nurse is focusing an interview on a patient's respiratory status. Which question should the nurse ask first to begin this interview?

Describe how you breathe for me?

A nurse is using Gordon's Functional Health Patterns model when assessing a client's strengths and areas needing improvement. What are areas that the nurse would include using this specific model? (Check all that apply.)

Nutrition/metabolism Values/beliefs Sleep/rest Activity/exercise Gordon has identified 11 functional patterns to assess when doing a health assessment--among others, these 11 include nutrition/metabolic, values/beliefs, sleep/rest, and activity/exercise. Although asking the client about medications and herbal supplements is part of the health history assessment, these areas are considered components of Gordon's model.

During the comprehensive health assessment, the nurse asks several questions relating to the client's family history of illnesses, such as diabetes and cancer. Why does the nurse do this? Select all that apply.

To identify genetic family trends for which the client is at risk To provide counseling and health teaching in high-risk areas To help identify those diseases for which the client may be at risk

A nurse is interviewing a client. Which nonverbal behavior by the nurse would best facilitate communication?

Using a moderate amount of eye contact

During the working phase of an interview the nurse encourages the client to continue and expand on the health issues. What technique is the nurse using?

active listening Active listening is the process of paying close attention to what the client is communicating, being aware of the client's emotional state, and using verbal and nonverbal skills to encourage the speaker to continue and expand. Empathy is the ability to perceive, reason, and communicate understanding of another person's feelings without criticism. Empowerment instills confidence in the client. Summarizing provides an overview of the client's story.

The nurse is beginning a health history interview with an adult client who expresses anger at the nurse. The best approach for dealing with an angry client is for the nurse to

allow the client to verbalize his or her feelings

While interviewing a client for the first time, the nurse is using a standardized nursing history form. The nurse should

maintain eye contact while asking the questions from the form. Establish eye contact when the client is speaking to you but look down at your notes from time to time.

Ability to perform self-care activities (or activities of daily living; ADLs) is a component of the health history that reveals the patient's quality of life. When assessing ADLs, the nurse asks if the patient can grasp small objects and open jars. This is an example of assessing the patient's:

mobility

Upon entering an exam room, the client states, "Well! I was getting ready to leave. My schedule is very busy and I don't have time to waste waiting until you have the time to see me!" Which response by the nurse would be most appropriate?

"You're certainly justified in being upset, but I am ready to begin your exam now."

The nurse is assessing a client's lifestyle and habits. At which time should the nurse assess the client for alcohol use?

After assessing for cigarette use

The nurse is teaching the patient how to self-administer insulin. Which functional health pattern does this nursing intervention address?

Health perception-health management

A client is having difficulty describing a chief complaint of chest pain. Which action by the nurse would be most appropriate?

Provide a laundry list of descriptive words

During an interview between a nurse and a client, the nurse and the client collaborate to identify problems and goals. This occurs during the phase of the interview termed

working

A clinic nurse has reviewed a new client's available health record and will now begin taking the client's health history. Which of the following questions should the nurse ask first when obtaining the health history?

"What is your major health concern at this time?"

The patient is being interviewed upon arrival in the Emergency Department. When collecting subjective data from the patient, the nurse is obtaining what other type of data from the patient?

Primary

A client is asked to describe "something that brings the most hope." Which functional health pattern is the nurse assessing?

value-belief

The nurse is taking a comprehensive health history on a new client. Why would it be essential for the nurse to obtain a complete description of the present illness?

To establish an accurate diagnosis A complete description of the present illness is essential to an accurate diagnosis.

When the nurse is assessing the value-belief health patterns of a client with a poor prognosis for a diagnosis of pancreatic cancer, which question would be most appropriate to ask?

"Where do you find your strength and hope?" Asking the client where the client finds strength and hope describes patterns of values, beliefs (including spiritual), and goals that guide choices and decisions. This would be important to identify for this client because the client is facing end-of-life issues. Asking the client how regular routines have changed fits within the activity-exercise health pattern. Asking the client how well the client thinks can manage care fits within the self-perception-self-concept health pattern. Asking if the client feels rested after a night of sleep fits within the sleep-rest health pattern.

Which statements provide information about a client's health maintenance? Select all that apply.

A child received immunizations based on the recommended schedule. A female client had a mammogram 2 weeks ago. A client recently a had lab test for liver function. Immunizations, screening tests, safety measures, and any lifestyle-related risk factors all provide information about a client's health maintenance. Past hospitalizations and surgical procedures do not provide information about health maintenance as this information does not capture ongoing health factors that impact the client's overall quality of health.

A nurse is interviewing an adult client who had a miscarriage 3 weeks ago. The woman is crying and is having difficulty talking. The nurse moves closer and places a hand on the woman's hand. What type of communication is this?

Active listening

Mrs. T. comes for her regular visit to the clinic. Her regular provider is on vacation, but the client did not want to wait. The nurse has heard about this client many times from colleagues and is aware that she is very talkative. Which of the following is a helpful technique to improve the quality of the interview for both provider and client?

Briefly summarize what the client says in the first 5 minutes and then try to have her focus on one aspect of what she discussed.

A client has just been admitted to the postsurgical unit from postanesthetic recovery, and the nurse is in the introductory phase of the client interview. Which of the following activities should the nurse perform first?

Explain the purpose of the interview. During the introductory phase, the nurse explains the purpose of the interview, discusses the types of questions that will be asked, explains the reason for taking notes, and assures the client about the confidentiality of the information. Collaborating to identify problems and obtaining family health history data are components of the working phase. Vital signs are not obtained during the interview.

A client reports a weight loss and fatigue during the review of systems. In which area should the nurse document this information?

General Information to document under the general area includes usual weight, recent weight change, any clothes that fit more tightly or loosely than before, weakness, fatigue, or fever. Information about weight and fatigue is not documented under the gastrointestinal system. Appetite and rest and sleep are not areas within the review of systems.

A nurse at the local free clinic is collecting data on a 16-year-old boy who has come to the clinic. Under what component of the health history would the nurse place data on whether the teen routinely uses seat belts when in a vehicle?

Health maintenance Health Maintenance—Safety measures: seat belts in cars, smoke/carbon monoxide detectors, sports helmets or padding, etc.

In the closing phase of the interview process, the nurse analyzes the data collected for what priority reason?

Identifying the primary problems or patterns of concern The nurse prioritizes, collects, and analyzes subjective and objective data and summarizes and states the two to three most important patterns or problems might be. The nurse's priority is not use the data gathered in the client interview as a baseline for interviewing the family or for communicating to the physician or other staff members.

When using an interpreter to facilitate an interview, where should the interpreter be positioned?

Next to the client, so the examiner can maintain eye contact and observe the nonverbal cues of the client A priority is for the examiner is to have a good view of the client and to avoid having to look back and forth between client and interpreter. The nurse should remember to use short simple phrases while speaking directly to the client and ask the client to repeat back what he or she understands.

A client admitted to the health care facility for new onset of abdominal pain expresses to the nurse that she was treated for gastroesophageal reflux disease in the past. In which section of the comprehensive health assessment should the nurse document this information?

Personal health history

The client is being interviewed upon arrival in the Emergency Department. When collecting subjective data from the client, the nurse is obtaining what other type of data from the client?

Primary Subjective data given by the client are considered primary data. Charts and family are sources of secondary data, while objective data are based upon tests, vital signs, and examinations. At present, no data are called tertiary.

A client scheduled for surgery tells the nurse that he is very anxious about the surgery. What is an appropriate action by the nurse when interacting with this client?

Provide simple and organized information

When recording the client's chief concerns during the health history, it is recommended that the interviewer do which of the following?

Quote the client's words. When recording the client's chief concern, it is preferable to quote the client's exact words whenever possible.

A nurse in the ED is assessing an adult client who, the nurse suspects, has been beaten by her husband. What is the nurse's legal obligation in this situation?

Report it to the nurse's supervisor When abuse is suspected, nurses are obligated to report it to a supervisor and obtain assistance from social work for further assessment. It is not necessary to call the police or counsel the client, but it is necessary to pursue the situation even if the client does not ask for help.

The nurse is preparing to assess the mental status of a 90-year-old client who is being admitted to the hospital from a long-term care facility. Which of the following should the nurse assess first?

The client's sensory abilities When interviewing an older client, you must first assess hearing acuity. Assessing hearing acuity is very important when interviewing older adult clients because hearing loss normally occurs with age, and undetected hearing loss is often misinterpreted as mental slowness or confusion. This must precede the other listed assessments.

During the client interview, the nurse asks specific questions such as "What were you doing when the pain started?" or "Was the pain relieved when you rested?" In what phase of the interview is the nurse involved?

Working

A client reports the health status of living parents, siblings, and deceased grandparents. What should the nurse do with this information?

create a genogram A genogram is a diagram of the family history. It provides a visual record that allows the provider to quickly identify disease patterns within the family. The family history does not need to be documented in a narrative note. This information is not part of the client's past medical history. It is not typically used when planning care.

A client is unable to recall the last time an immunization was received. Which part of the client's health should the nurse realize is being the most impacted by this practice?

health maintenance

An older client cannot recall the date of a surgical procedure but the adult daughter interjects with the exact date because it occurred a week before her wedding. How should the nurse document this information?

last surgery date validated by adult daughter

The nurse conducts a health history with a client who reports having a dull headache over the past month. The client tells the nurse that using aromatherapy scents have helped manage the pain sometimes. This information is belongs to which attribute of a symptom?

treatment

Nonverbal communication is a very important aspect in nurse-client relationships. What can the nurse do to help gain trust in clients? Select all that apply.

-Do not use facial expressions such as rolling the eyes or looking bored or disgusted -Use gestures intentionally to illustrate points, especially for clients who cannot communicate verbally -Make sure that dress and appearance are professional

A client has a 10-year history of being treated for hypertension. Where should the nurse document this information?

past medical history

You are taking a health history on a new patient. While performing your assessment, the patient informs you that her mother has type 1 diabetes. What is the significance of this information to the health history?

The patient may be at risk for developing diabetes

Which type of question is asked first by the nurse in order to attain a full description of the client's symptoms and to generate and test diagnostic hypotheses?

open-ended questions to encourage the client to tell his or her story

A nurse is interviewing a client complaining of abdominal pain for the last 2 weeks. Why is a history of the present illness vital to treating this client?

A complete description of the present illness is essential to an accurate diagnosis The nurse collects information about the present illness by beginning with open-ended questions and have the client explain symptoms. A complete description of the present illness is essential to an accurate diagnosis. Nurses do not diagnose the problem for which the client is seeking medical help; even if knowing where the pain is, it is necessary for a nurse to take a complete health history. It is important to know not only where the pain started but also the quality and intensity of the pain as well as what aggravates or alleviates the pain.

While completing a history of present illness the nurse asks the client about risk factors. In which way should the nurse use this information?

Analyze as a contributing factor to the current problem Risk factors or other pertinent information related to the symptom is frequently relevant, such as risk factors for health problem or a current medication that may have side effects similar to the complaint. Risk factors are not used to determine health teaching, identify a genetic cause, or determine if a family history of the problem exists.

An adult client is brought to the ED after falling 12 feet from a ladder. The client has an obvious deformity to his left lower leg. What kind of assessment is the nurse going to perform?

Emergency An emergency assessment occurs when the client's condition is unstable. A focused assessment covers one subject, usually the current illness. A comprehensive assessment covers every system in the body, including a past history and a family history. A head-to-toe assessment is a complete physical assessment of the body.

A client is being admitted to a rehabilitation facility after having a stroke. Which type of assessment should the nurse complete with this client?

Comprehensive When admitting a client to facility, a comprehensive assessment is completed. This assessment includes current health problems, past history, family history, a review of body systems, and health patterns. It provides a basis for assessing client concerns, health status, risk factors, and health promotion. A focused or problem-oriented assessment focuses on the client's current problem. The client's symptoms, age, and this history will determine the extent of the physical examination to perform. A follow-up history is a form of a focused assessment. The client is returning to have a problem evaluated after treatment. Data is gathered to evaluate if the treatment plan was successful.

The nurse is assessing a client's sexual history. Which question should be included regardless of the presenting problem?

Concerns about HIV or AIDS It is important to ask all clients, "Do you have any concerns about HIV infection or AIDS?" even if no explicit risk factors are evident. Questions may be asked about birth control, last sexual experience, and partner preference according to the situation.

The client presents to the clinic reporting chest pain and shortness of breath. Which type of health history would the nurse would conduct?

Emergency Reports of chest pain and shortness of breath can indicate a life-threatening situation, such as myocardial infarction. The nurse needs to quickly collect information regarding the presenting problem and act to stabilize the client. A comprehensive health history would not be appropriate at this time, because information about demographics, family history, functional and psychosocial status, and review of systems is not a priority. A focused assessment is not appropriate for the client presenting with a potential life-threatening situation.

A client arrives at the Emergency Department reporting shortness of breath. She is cyanotic with bilateral wheezing. The client begins to gasp for air and cannot speak. The nurse begins to gather information so that interventions can resolve the immediate breathing problem. Her assessment and interventions are concurrent. The nurse is performing what type of health history?

Emergency The nurse is performing an emergency health history, the purpose of which is to collect the most important information and defer obtaining details until the client is stable. The focused health history involves questions that relate to the current situation. The comprehensive health history takes place during an annual physical examination. There is not a primary health history for clients.

The nurse is in the introductory phase of the client interview. Which of the following activities would be appropriate?

Explaining the purpose of the interview During the introductory phase, the nurse explains the purpose of the interview, discusses the types of questions that will be asked, explains the reason for taking notes, and assures the client about the confidentiality of the information. Collaborating to identify problems, determining the reason for seeking care, and obtaining family health history data are components of the working phase.

A genogram is developed to visually show what?

Family health patterns A common tool used to understand family health patterns is the genogram. This graphic representation allows the nurse to map family structures and compile a large amount of information visually. Genograms make it easier for the nurse to identify the complexity of families and validate patterns pertinent to clients. A genogram is much more than a family tree showing family relationships or nationalities of family members.

The review of systems component of the health history is best described as a:

Focus on common questions and issues related to each of the different body systems The review of systems is a systematic method of addressing common questions, symptoms, and issues, rather than specific diseases, of the major body systems. As it is an overview, there should not be a large number or detailed investigation of questions about each system. Given the focus on identifying symptoms, it would be simplistic to describe it as simply a series of head-to-toe questions.

A client with hypertension seeks medical attention for a new onset of a nosebleed. Which type of assessment should the nurse complete with this client?

Focused A focused or problem-oriented assessment focuses on the client's current problem. The client's symptoms, age, and this history will determine the extent of the physical examination to perform. An emergent or emergency assessment focuses on a specific problem that may be life-threatening. This type of assessment focuses on circulation, airway, and breathing (CAB) when cardiac arrest is suspected. A follow-up history is a form of a focused assessment. The client is returning to have a problem evaluated after treatment. Data is gathered to evaluate if the treatment plan was successful. A comprehensive assessment is completed when admitting a client to a facility.

Which action should a nurse implement when assessing a non-native client to facilitate collection of subjective data?

Maintain a professional distance during assessment When assessing a non-native client, the nurse should maintain a professional distance during assessment; the size of personal space affects one's comfortable interpersonal distance. The nurse should not speak to the client using local slang because, if the client finds it difficult to learn the proper language, slang would be much more difficult to understand. The nurse need not avoid any eye contact with the client, but should maintain eye contact with the client as required, without giving the client reason to think that the nurse is being rude. Asking one of the client's significant others to interpret during the interview may actually impair the assessment process. In addition, health care institutions often have specific policies regarding interpreters that you must be aware of prior to using an interpreter.

Prior to a client interview, the nurse collects information from the client's medical record, such as prior surgeries, home medications, allergies, and past treatments. What phase of the interview process is this?

Preinteraction

A client is describing a very personal part of her history very quickly and in great detail. How should the nurse react to this?

Push away from the keyboard or put down the pen. This is a common event in clinical practice. It is much more important to listen actively with good eye contact at this time than to document the story verbatim. The nurse wants to minimize interruptions, such as asking the client to repeat phrases. It is usually not appropriate to ask a client to go over the written note, but it would be a good idea to repeat back to her verbally the main ideas once she has completed her story. By putting down the pen or pushing away from the keyboard, the nurse lets the client know that her story is the most important thing at this moment.

When recording the patient's reason for seeking care (chief concerns) during the health history, it is recommended that the interviewer:

Quote the patient's words

A comprehensive health history includes which components? Select all that apply.

Reason for seeking care History of present illness Past health history Usually the nurse collects demographical data first and then elicits from clients a complete description of their reason for seeking care, because that information usually is most important. The nurse collects information about the present illness by beginning with open-ended questions and having clients explain symptoms. A complete description of the present illness is essential to an accurate diagnosis.

A student nurse is conducting her first client interview. The student suddenly draws a blank on what to ask the client next. What is a useful interview technique for the student to use at this point?

Summarization Summarization can be used at different points in the interview to structure the visit, especially at times of transition. This technique also allows the nurse to organize his or her clinical reasoning and to convey it to the client, making the relationship more collaborative. It is also a useful technique for learners when they draw a blank on what to ask the client next.

A nurse is collecting data on a client's chief complaint, which is a spell of numbness and tingling on her left side. Which of the following questions would be best for eliciting information related to associated factors?

What other symptoms occurred during the spell?" Examples of questions related to associated factors include the following: "What other symptoms occur with it? How does it affect you? What do you think caused it to start? Do you have any other problems that seem related to it? How does it affect your life and daily activities?" The question, "How bad was the tingling and numbness?" relates to severity. The question, "How long did the spell last?" relates to duration. The question, "Where did the numbness and tingling occur?" relates to location.

During a client interview, the nurse asks questions about the client's past health history. The primary purpose of asking about past health problems is to

identify risk factors to the client and his or her significant others. The past health history focuses on questions related to the client's personal history, from the earliest beginnings to the present. These questions elicit data related to the client's strengths and weaknesses in his or her health history. The information gained from these questions assists the nurse in identifying risk factors that stem from previous health problems. Risk factors may be to the client or significant others.

Ability to perform self-care activities (or activities of daily living; ADLs) is a component of the health history that reveals the client's quality of life. When assessing ADLs, the nurse asks if the client can grasp small objects and open jars. This is an example of assessing the client's:

mobility This is an example of assessing the client's mobility. Self-perception is how the client views himself or herself. Home maintenance includes such things as housekeeping chores, cooking, shopping, and driving. Values and beliefs guide a person's choices or decisions.